Medical labour under neoliberalism: an ethnographic study in Colombia
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ORIGINAL ARTICLE
Medical labour under neoliberalism: an ethnographic study in Colombia Adriana Ardila-Sierra1
•
Ce´sar Abadı´a-Barrero2
Received: 30 January 2020 / Revised: 11 June 2020 / Accepted: 22 June 2020 Swiss School of Public Health (SSPH+) 2020
Abstract Objectives In order to increase the knowledge about the impacts of neoliberal market forces on physician’s labour, this article’s objectives are to analyse how and why the labour of physicians is transformed by neoliberalism, and the implications of these transformations for patient care. Methods Ethnographic investigation is carried out through semi-structured interviews with 20 general practitioners at public and private facilities in Colombia. The interviews were contrasted with national studies of physician’s labour since the 1960s. A ‘‘mock’’ job search was also simulated. The analysis was guided by Marxian frameworks. The study was approved by a Human Research Ethics Committee, and informed consent was obtained from all participants. Results The overpowering for-profit administration of the Colombian healthcare system imposes productivity mechanisms on physicians as a result of a deregulated labour market characterized by low salaries, reduced and self-funded social security benefits, and job insecurity. Overworked physicians with reduced autonomy become frustrated for not being able to provide the care their patients need according to clinical standards. Conclusions Under neoliberal conditions, medical labour becomes exploitable and directly productive through its formal and real subsumption to Capital. The negative consequences of a progressive loss in physician’s autonomy unveil the incompatibility between neoliberal health systems and people’s health. Keywords Employment Clinical medicine Physician–patient relations Quality of health care Neoliberalism Exploitation
Introduction The organization, financing, and delivery of health services in Colombia have been drastically transformed since the 1990s with the consolidation of a market-based or neoliberal healthcare reform. This reform, based on the ‘‘structured pluralism’’ model (London˜o and Frenk 1997), proposes that a mix of public and private insurance companies and healthcare institutions enter into competition in This article is part of the special issue ‘‘Market-driven forces and Public Health’’. & Adriana Ardila-Sierra [email protected] Ce´sar Abadı´a-Barrero [email protected] 1
Universidad Nacional de Colombia, Bogota´, Colombia
2
University of Connecticut, Mansfield, CT, USA
a ‘‘regulated market.’’ Regulation, however, has been one of the reform’s significant challenges (Bauhoff et al. 2018; Prada and Chaves 2019). The population was divided into two regimes: those who could purchase insurance (i.e. contributory regime) and those who needed governmental subsidies to enter into the insurance market (i.e. subsidiary regime.) Given its funding mechanisms and the increase in the number of people with insurance, this r
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